Case Report
Screening and Construction of Score Based Risk Factors Assessment Questionnaire for Earlier Detection of Type-2 Diabetes Mellitus among Tangail Population
Ushin Fatima1
, Md. Moniruzzaman2
, Papia Jahan1
, Abdullah-Al-Emran1
,
Fatma Ercanli-Huffman3
, and Ashraf HossainTalukder1*
1Department of Biotechnology and Genetic Engineering,
Mawlana Bhashani Science and Technology University, Santosh, Tangail, Bangladesh
2Molecular Biotechnology Division, National Institute of Biotechnology, Ganakbari, Ashulia, Savar, Dhaka-1349
3Department of Dietetics and Nutrition, Florida International University, Miami, FL 33199, USA
*Corresponding author: Ashraf Hossain Talukder, Department of Biotechnology and Genetic Engineering, Mawlana Bhashani Science and Technology University, Santosh, Tangail, Bangladesh, Tel: +881818726279, Fax: +88921 519; Email:
ashraf82_bmb@yahoo.com
Submitted: 21 January 2019; Accepted: 17 April 2019; Published: 19 April 2019
Cite this article: Fatima U, Moniruzzaman M, Jahan P, Al-Emran A, Ercanli-Huffman F, et al. (2019) Screening and Construction of Score Based Risk Factors
Assessment Questionnaire for Earlier Detection of Type-2 Diabetes Mellitus among Tangail Population. JSM Endocrinol Diabetes Obes 3: 7.
Diabetes is a metabolic disorder, which is a foremost health
problem in the world [1]. There are two major forms of diabetes,
type 1 [previously called insulin-dependent diabetes mellitus,
IDDM or juvenile-onset diabetes, an autoimmune disease
resulting in the destruction of insulin- producing cells] and type
2 [previously called noninsulin-dependent diabetes mellitus,
NIDDM or maturity-onset diabetes] [2]. In type 2 diabetes
[T2D], the pancreas is usually producing enough insulin, but
for unknown reasons the body does not respond to the insulin
effectively, a condition known as insulin resistance and after several years, insulin production decreases [3]. At present, the
diabetic population number in Bangladesh is 8.4 million, which
is expected to double by 2]3], according to International Diabetes
Federation [Islam and Rahman 2] [12]. Moreover, [9]- 95] % of
the diabetic patients in Bangladesh have T2D. [4]. But only a few
population based studies on T2D are undertaken in Bangladesh
which is not sufficient for proper management [5-9] and most
of the studies done based on prevalence of T2D and assessment
of different risk factors of T2D [1]-15]. To realize the risk of T2D
many developed countries already have made an approach to
identify risk factors of T2D for their population and from these
to develop a score based questionnaire subsequently such as
Australia [16], Canada [17], Finland [18], Libya [19], Qatar [ 2]],
West Indies [ 21] etc. From the previous studies 16 risk factors
were considered for T2D assessment in Tangail population which
includes- age, gender, hereditary, previous health examination,
use of anti-hypersensitive drugs, smoking, food habit, physical
activity, body mass index [BMI], waist circumference, mental
trauma, uptake of red meat, hypertension, heart disease [5-
15]. Similar studies also done for other disease like asthma
[22] and heart diseases [23, 24]. Therefore, the aim of our
study was to identify whether the significant risk factors from
these 16 extracted factors are associated with T2D in Tangail
population and from these to make a score based risk evaluation
questionnaire from which it will be possible to predict the occurrence of T2D earlier.
Research Design and Methods
Study design
First the population of Tangail was stratified according to
diabetic or non- diabetic, gender and age. Then the principle of
random sampling was used in each stratified area.
Study area and Population
This study was conducted in Tangail district of Dhaka Division
in Bangladesh over a period from January to May of 2]12. Tangail
was selected as a study area because it contains both rural and
urban dwellers. The population of Tangail is 3253961 with nearly
half male and female [5].]2% male] [49.98% female] [5]. Data
from 4]] people with and without type 2 diabetes were collected from Diabetes Hospital of Tangail who came for regular checkup
in this hospital that covers the different Thana of this district by
purposive sampling process. An ethical approval was obtained
from the Research Ethics Committee of Bangladesh Institute
of Research and Rehabilitation in Diabetes, Endocrine and
Metabolic Disorders [BIRDEM] hospital [Reference no: BIRDEM/
Ethics/2]12/45] before distributing the questionnaires. After
an oral glucose tolerance test [OGTT] which includes both a
fasting plasma glucose [FPG] and a 2-hour glucose level following
administration of 75 g of glucose, we selected 2]] people who
were type 2 diabetic patients and 2]] people who were not
diabetic patients. A diabetic patient was considered who had
a fasting blood glucose level ≥ 7.] mmol/L and 2-hour postprandial
reading of ≥ 11.1 mmol/L. Both men and women of 25-
86 years ages were considered eligible as type 2 diabetic patients
and for controls. After selection of type 2 diabetics and controls,
the annual face-to-face survey was conducted in the hospital.
The exclusion criteria was previously diagnosed diabetes, severe
renal disease, disease with a strong impact on life expectancy,
and therapy with drugs known to influence glucose tolerance
[thiazide diuretics, artery -blockers, and steroids], patients with
type 1 diabetes who were confirmed by their general practitioner
or doctors of that hospital as having type 1 diabetes, gestational
diabetes, and pregnant women.
Questionnaire design
Based on a literature review a well-organized questionnaire
was developed and tested with a pilot survey. The same
questionnaires were designed for both type 2 diabetic patients
and those free of diabetes [control group]. Sixteen risk factors
were selected from the literature review and data were collected
based on these risk factors. After the pilot study, some necessary
corrections and modifications were needed for the validity of the
questions. The questionnaire was modified and 14 risk factors
were selected for the final questionnaire. These 14 risk factors
included age, gender, BMI [body mass index], hereditary, waist
circumference, red meat intake, smoking, mental trauma, heart
disease, systolic blood pressure, diastolic blood pressure, food
habit [eating plentiful vegetables and fruits], physical activity
[at least 3] minutes walking in morning and evening everyday
including normal daily activity], and medication.
Physical measurements
Weight was measured in kilogram and height in meter to
obtain BMI as the ratio of weight to the square of heights in
kilogram/meter2. Calculations of weight from participants were
done by weight machine without shoes and any objects in the
pocket. The heights were taken from toes of bare feet to head.
According to the revised standards for adult obesity in Asia
obese, overweight and healthy weight was classified [25]. Waist
circumference was measured midway between the lowest rib
and top of the iliac crest in meters by meter scale; where waist
circumferences ≥ ].9] meter for males and ≥ ].8] meter for females
were considered a risk factor for T2D [Chen et al. 2]1]]. Moreover,
hypertension was also identified through WHO criteria as systolic
blood pressure [SBP] ≥ 14] mmHg and diastolic blood pressure ≥
9] mmHg or currently taking medication for high blood pressure.
Zero mercury sphygmomanometer was used to measure SBP and
DBP from left arm of participants while seated. Two reading were
taken 5 minutes apart and the mean of the two was recorded as
final blood pressure.
Behavioral risk measurements
A positive response for physical activity of participants was
considered those who usually do walking or physical work daily
at least 3] minutes or more. Daily, occasional smokers and nonsmokers
were classified according to currently smoking habit
of non-diabetic participants and previous smoking record of
diabetic patients as a risk factor of T2D.
Statistical analysis
Statistical Package for Social Sciences [SPSS, version 14, SPSS
Inc. Chicago, Illinois, USA] software was used to analyze obtained
data for defining significant risk factors. ‘Risk relative ratio’ with
95% confidence interval [CI] of all risk factors was generated in
the cross tabulation model. The significant and non-significant
risk factors were classified on the basis of p-value that is described
in Table 1 and those with p < ].]5 values were considered for
the development of t h e final questionnaire. Significant risk
factors were determined from relative risk ratio using the χ2 [chi
square] test. Scores of significant risk factors were calculated on
the basis of odds ratio [OR] with 95% CI in the binary logistic
model. Age ranges were established to find the highest risk age category. The final questionnaire was compared with hereditary
and age prediction of accuracy level of the questionnaire through
Receiver Operating Characteristic [ROC] curves. A score ranges
for risk of developing T2D were established on the basis of the most appropriate sensitivity-specificity ratio of different cut-off score points.
After pilot survey 14 risk factors were considered as variables
for statistical analysis. Among these fourteen risk factors age and
hereditary were more significant independent risk factors for
diabetes. 69.5% of patients with diabetes were ≥ 45 years of age.
Table1 shows the frequency of significant and non-significant risk
factors and significant risk factors are separated here on the basis
of their p value. Moreover, Table 2 describes that the prevalence
of T2D of > 64 years group were 3.22[RR] [95% CI, 1.56-6.63]
times higher than individuals aged 55–64 years. In the same way, patients of 55-64 years had prevalence of T2D 1.66[RR] [95% CI,
1.]7-2.57] times more likely than 45–54 years-old. Furthermore,
the hereditary of diabetes [RR 2.268, 95% CI 1.792- 2.889, p <
].]]1] and uptake of red meat [p < ].]]1, RR 1.826, 95% CI 1.225-
2.929] were the most significant risk factors while BMI [p= ].]39,
RR 1.258, 95% CI 1.]1]-1.583], physical activity [p= ].]42, RR
1.269,95% CI 1.]]7-1.629] and waist circumference [measure of
obesity] [p= ].]37, RR 1.26, 95% CI 1.]13-1.6]3] were found as
significant risk factors from their independent relative risk ratio.
Seven risk factors were eliminated because they were not
significant including food habit, mental trauma, heart disease,
medication, SBP and DBP. A history of smoking was omitted
in this analysis because most females in our country are not
habituated with smoking for their religion or social rituals and
male patients could not quantify units of smoking accurately. The
characteristics and significance levels of the all risk factors were
displayed in Table 1.
The odds ratio for all the off to the nearest integer to obtain
the final score points for the variables ranges and these score
points were shown in Table 3. The total score points obtained
in the scorecard was 23. However, the entire sample of 4]]
participants yielded an AUC of ].836 for the seven risk factors
[total risk associated questionnaire] in both ROC curves [ Figure
1]. The total risk associated questionnaire [AUC ].836] was
significantly better than age [AUC ].64]] and hereditary [AUC
].688]. Before choosing a minimum score, several cut-off scores
were examined with respect to specificity and sensitivity Table
4. 97% sensitivity was found for score of ≥ 1] with acceptable
specificity. However, a cut-off score of 18 was chosen with a
high specificity [95%] to minimize additional testing and false
positive results to maximum 5%. On the basis of percentage of
diabetic patients, risk scores were divided into four categories
[negligible, low, high and very high] [Table 5]. Age, gender,
waist circumference, BMI, physical activity and red meat- risk
factors were combined to form a modifiable risk factors score
[9 modifiable Criterions in total]. The positive likelihood ratios
[LR+] were > 1.] whereas; the negative likelihood ratios [LR-]
were < 1.] for all score categories [Table 4].
Discussion and Conclusion
The World Health Organization [WHO] ranked 1] countries according to the highest diabetic patients where Bangladesh was
in 1]th position for 2]]] and will be t he 7th position for 2]3] [1]. The
risk assessment tools for T2D diabetes has been developed for
diagnosis of T2D at early stage on the basis of 7 risk factors [age,
hereditary, physical activity, red meat, BMI, waist circumference
and gender] were identified as significant risk factors [p< ].]5]
and these risks factors are easily self-assessed.
Among the risk factors, age, hereditary and uptake of red
meat were the most significant followed by BMI. Smoking and
alcohol were not significant. This may be attributed to the Tangail
people’s lifestyle. In the Tangail district the majority of people live
in rural areas. BMI, waist circumference and smoking received
higher scores in the final questionnaire of many countries like
AUSDRISK [16], CANRISK [17], and TRAQ-D [21]. This may be
since Asian people have smaller waist circumferences and BMI
than in people of Europe origin [1]]. The people aged > 64 were
at the highest risk to attain T2D; whereas, the lowest score was
found for people of < 35 years. Moreover, the prevalence of T2D
in the individuals aged 55- 64 were higher than aged 45-54 and
35-44. The results were consistent with other studies conducted
in Bangladesh [1]-13]. The prevalence of diabetes increased with
increasing age. Hereditary was the second most proximal risk
factor in the Tangail area. Hereditary was a leading risk factor for
53.5% of T2D patients. Some studies also found strong relation
between family history and T2D incidence [1], 14, and 15]. The
percentage of male participants [54.8%] with T2D was hi gher
than that of female participants [43.2%]. This data was supported
by the IDF atlas which reported that 63% of the T2D patients
were male [26]. In contrast, most of the studies conducted in
Bangladesh found higher occurrence of the disease among female
[8, 13, 14, and 27]. Therefore, gender and lifestyle of people play
a significant role in T2D occurrence. Lifestyle variables consist
of four risk factors- BMI, waist circumference, physical activity
and red meat uptake. Approximately one-third [36%] of diabetic
patients did not meet minimum physical activity requirements
[3] minutes, twice per day], making low physical activity a
significance risk factor. On the other hand, 39.5% of the total
diabetic patients consumed red meat making it on par with
low physical activity as a risk factor. To our knowledge it is the
first study which included red meat intake history as variables.
Moreover, 17.5% of the total diabetic patients were overweight:
17.8% had BMI >25 and 17.8% of the total diabetic patient had
waist circumference over 9]. This result was similar with the
other studies of Bangladesh [17-24]. The score points from the
four risk factors were considered as a modifiable risk factors. The
mean numbers of modifiable risk factors among patients without
and with diabetes < 65 years were 2.]3 and 6 respectively. Among
diabetic patients, 95% had a modifiable risk factor score of > 3. If
they ceased eating red meat, reduced their weight and decreased
their waist circumference and engaged in walking continuously
for 3] minutes twice per day, overall 65% of all participants could
have reduced their diabetic risk score by an average of 6.4 points.
A risk estimate can be made on the basis of a combination of
risk factors, rather than using a single cut-off value. A positive
likelihood ratio > 1.] for a diagnostic test is considered to be
strong evidence to ‘rule in’ disease, whereas a negative likelihood ratio < 1.] is considered sufficient evidence to ‘rule out’ disease.
From the Table 5, it was found that if any participant does score ≤
8, it can be considered as negligible score. This is because in this
range, presentence diabetic patient was very low. Similarly, the
range of score points- 9-11, 12-15, ≥ 16 were considered as low,
high, very high risk respectively as prevalence of T2D.
In the conclusion, a simple and easily self-administered
scorecard can be developed using statistically significant risk
factors. This could be a screening tool for the population of Tangail
fo r the early detection of T2D.The final questionnaire prepared
from this study was an approach to predict T2D among Tangail
population. This score-based T2D risk assessment tool may play
a role in assessing current risk of occurring T2D and prevalence
of T2D for next 5 or 1] years of Tangail people. Moreover, this tool
can be used in public health campaigns and public health care
centers of Tangail.
Limitation and Further Study
The limitations of the study were the small sample size and
that ethnicity is not included as a risk factor. Another limitation
could be that smoking, hypertension and food habits were not
found as significant risk factors because most of the participants
in this study were from rural areas where there are healthier
lifestyles than in urban areas. Future studies should be conducted
with a representative sample of Bangladesh people including
urban, rural and tribal people of different areas of Bangladesh.
These studies should consider additional relevant demographic
and clinical measures.
During collection of data written consent was taken from
literate volunteers both in English and native language and
verbal consent was taken from those who are ill.
The authors are grateful to the all participants who make
this study feasible. Special thanks to Professor Fatma Ercanli-
Huffman, Department of Dietetics and Nutrition, Florida
International University, USA for her critical language and copy
edit the manuscript as native English speaker personnel.
AM UF conceived the research idea and perform the data
collection. UF, MM and PJ actively involved in the data collection
and PJ, UF perform the statistical analysis and results preparation.
AAE and AHT helped in designing the study and supervision of the
work.and PJ prepared the manuscript. AHT and AAE contributed
intellectual thought, final revision and editing of the manuscript.
All authors have read and approved the submitted version of
manuscript.